Basic Information
| Provider Information | |||||||||
| NPI: | 1396001517 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN, FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 278 | ||||||||
| Address2: | |||||||||
| City: | WOODBURN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9719835260 | ||||||||
| FaxNumber: | 9719835326 | ||||||||
| Practice Location | |||||||||
| Address1: | 347 FAIRVIEW STREET | ||||||||
| Address2: | |||||||||
| City: | SILVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9719835360 | ||||||||
| FaxNumber: | 9719835370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2012 | ||||||||
| LastUpdateDate: | 10/25/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 201404734NP-PP | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 201404734NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 500677059 | 05 | OR | MEDICAID |